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Adolescent Girl -Form Fill
Survey Information
Q01
Unique reference ID of the household
Q02
Member code
Q03
Does this adolescent belong to this household?
Yes
No
Q04
First Visit
Q04_1
Interviewer name
Q04_2
Interviewer code
Q04_3
Date of the interview
Q04_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
Q05
Second Visit
Q05_1
Interviewer name
Q05_2
Interviewer code
Q05_3
Date of the interview
Q05_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
Q06
Third Visit
Q06_1
Interviewer name
Q06_2
Interviewer code
Q06_3
Date of the interview
Q06_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
Q07
RECORD TIME WHEN YOU START THE INTERVIEW.
Respondent Information
A01
What is the name of the adolescent?
A02
What is the age of the adolescent?
A03
Please specify your caste.
Scheduled Caste
Scheduled Tribe
Other Backward Class
General
Others (Specify)
Don’t know
A04
Please specify your religion
Hindu
Muslim
Christian
Sikh
Buddhist/neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No religion
Others (Specify)
Don’t know
A05
Who is the Respondent?
Self
Parent
A06
Do you/ Does this adolescent suffer from any of the following comorbidities?
Type 1 diabetes
Low blood pressure
High blood pressure
Congenital heart disease
Asthma
Cancer
Tuberculosis
Attention-deficit hyperactivity disorder. (ADHD)
Mental health issues such as anxiety or depression
Learning difficulties
No comorbidity
Other chronic ailment
A07
Do you/ Does this adolescent go to school?
Yes
No
A08
Has the adolescent girl started her menses?
Yes
No
A09
Is the adolescent girl married?
Yes
No
A10
Does the adolescent live in the natal household or in husband’s
Natal household
household
Lives in another household
Others
A11
Has the adolescent girl ever been pregnant?
Yes
No
A12
How many times has the adolescent girl been pregnant?
A13
Serial number of pregnancies
A14
What was the outcome of the pregnancy?
Born Alive
Still Birth
Abortion
Miscarriage
No outcome
A15
What was the year of the pregnancy outcome?
A16
How many months were you pregnant when the outcome happened?
A17
Was this a single/mult iple
Single
Multiple
A18
Is the child alive?
Yes
No
A19
At present how many months old the child
Respondent Knowledge and Counselling Support
B01
Did you/ your adolescent receive any advice/ counselling on anaemia/ anaemia prevention by any adult?
Yes
No
B02
From whom did you / your adolescent receive the advice related to anemia?
Medical Doctor
Nurse
ASHA
ANM
AWW
Traditional/spiritual healer
Teacher
Non-teaching staff at school
Peer educator
Others
B03
According to you, what are the symptoms of anaemia?
Feeling dizzy/giddiness
Feeling tired/weak
Paleness on face and skin
Lack of appetite
Lack of interest in studies
Others
Do Not Know
B04
According to you what are the causes of anaemia?
Not Consuming Iron Rich Diet
Not Taking Iron Supplementation During Pregnancy
No Interval Between Subsequent Pregnancies
Increased Blood Loss During Periods
Due To Hookworm Infestation
Drinking water contaminated by fluorides
Others
Do Not Know
B05
According to you, what could be the treatment for anemia?
Consumption of Iron Supplements/IFA Syrup and Tablets
Consumption of Iron Rich Food
Others
Do Not Know
B06
Have you heard of Iron Folic Acid (IFA)
Yes
No
B07
When should IFA tablets be consumed?
Half hour to One hour after meals
Others (specify)
Do not know
B08
Can IFA tablets consumed along with tea/coffee?
Yes
No
B09
Can IFA tablets be consumed with foods rich in Vitamin – C (like lemon, amla,orange, guava etc.)?
Yes
No
Preventive Population-Level Interventions
C01
Have the eyes, tongue, nails, palms of the hand, skin, of the you/ your adolescent ever been visually checked for anemia, by a provider?
C01A
Coverage
Yes
No
C01B
Was this done over the last 12 months?
Yes
No
C01C
When was this done?
C02
Has any health provider taken your / your adolescent’s blood sample for anaemia testing?
C02A
Coverage
Yes
No
C02B
Was this done over the last 12 months?
Yes
No
C02C
When was this done?
C03
Did you / your adolescent ever receive iron folic acid tablets from anyone in the last one year?
Yes
No
C04
How many tablets did you/ your adolescent receive in last 3 months?
C05
When did you/ your adolescent last receive the IFA Tablets?
C06
Who provided you/ your adolescent with the tablet(s)?
Medical Doctor
Nurse
ASHA
ANM
AWW
Traditional/spiritual healer
Teacher
Non-teaching staff at school
Peer educator
Others
C07
Where did you / your adolescent receive the tablet(s)?
Medical College
District Hospital and Sub-District Hospital
Community Health Centre – FRU/ CHC-Non-FRU
Primary Health Centre/U-PHC
Sub Centre / Health and Wellness Centres
Private hospital (with IPD)
Private clinic (only OPD)
Private clinic (homeopathy/ayurvedic/AYUSH)
NGO/Charitable Hospital
Pharmacy
Physiotherapy Centre
Traditional Healer
Tele-consultation (e-Sanjeevani OPD)
Mobile Health Units
VHSND
Anganwadi Centre
At School
Others
C08
Did you consume all the IFA tablets last received?
Yes
No
C09
Why did you / your adolescent not consume the IFA tablet?
Bad taste/smell
Forgot to consume
Had nausea after consuming earlier
Had abdominal pain after earlier consumption
Had an upset stomach after earlier consumption
Did not feel it was required
Mother-in-law/mother/guardian advised me not to
Social/religious reasons
Perceived it to be unsafe
Others
C10
Did you / your adolescent ever receive albendazole from anyone?
Yes
No
C11
Did you / your adolescent consume the Albendazole tablet last received?
Yes
No
C12
Why did you / your adolescent not consume the Albendazole tablet?
Forgot to consume
Had nausea after consuming earlier
Had vomiting/diarrhoea after earlier consumption
Had excessive hair loss after earlier consumption
Did not feel it was required
Mother-in-law/mother/guardian advised me not to
Social/religious reasons
Perceived it to be unsafe
Others
C13
Is Kishori Diwas celebrated in your GP?
Yes
No
C14
What topics are discussed in Kishori Diwas meetings?
IFA and Deworming procedures
Menstrual Hygiene
Counselling girls to join school
Personality Development
Others
C15
Have Kishori Samuh’s created in your GP ?
Yes
No
C16
What are the activities undertaken under Kishori Samooh?
Peer Monitoring
Peer learning and support
Counselling services
Skill Development
Others
C17
Do you receive Mid-Day meals at school regularly?
Yes
No
C18
How is the quality of the food received in Mid-day meal?
Good
Above average
Average
Below Average
Bad
Others
C19
Which menstrual hygiene product do you/ your adolescent use?
Cloth
Locally Prepared Napkins
Sanitary Napkins
No specific product used
Others
C20
Why do you / your adolescent prefer this product?
Ease of availability
Comfort to use
Comfort for disposable
Was provided by a frontline worker
Others
C21
Was this product provided to you / your adolescent or did you purchase?
Provided by frontline worker (ASHA/AWW) at home
Provided while visiting Adolescent Friendly Health Clinic
Provided by School
Purchased using own money
C22
Were you / your adolescent ever provided counselling by a frontline worker on menstrual health and hygiene?
Yes
No
C23
Who among the following provided the counselling on Menstrual Health and Hygiene.
ASHA
AWW
SHG Family member
SHG member
VO member
SAC member
ICRP-FNHW/Swasthya Sakhi
Others (Specify)
Don’t Know
C24
Have you/your adolescent ever received take home rations from the Anganwadi/ICDS centre?
Yes
No
C25
How much take home rations (have you received from Anganwadi/ICDS centre in last 3 months?
C26
Record time when you end the interview
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